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By M. Jorn. Providence College.

The forms in which Viagra can be used are also being developed and before long there will be several different ways in which it can be administered orlistat 120mg without a prescription. Side effects With the publicity for these drugs have come reports of some potentially dangerous and unpredictable effects 60 mg orlistat with mastercard. SEXUAL RELATIONSHIPS 63 We have already noted that they work on the vascular system discount 120mg orlistat with visa. Most reports have centred on vascular incidents generic orlistat 120mg on line, such as deaths from heart attacks order orlistat 120 mg with visa. In the population at large, impotence and erection problems increase with age, and so statistically much of the demand has come from older men. However, cardiovascular problems – heart disease and high blood pressure – also increase with age. Although these drugs have been found to enhance erectile function in those with such problems, men who are taking medications such as organic nitrates, which reduce blood pressure, e. In addition, and a rather obvious point, sexual activity, and particularly sexual intercourse, involves vigorous exercise, and men who have undertaken almost no exercise for several years, perhaps with an underlying undiagnosed cardiac problem, may find themselves in difficulty – as in undertaking any vigorous activity without prior preparation. However, because many men with MS are in younger age groups than those in which major problems have occurred, it is likely that the difficulties will be found to be fewer amongst most men with MS. Other help available Even if the nerve pathways from the brain to the penis are damaged in the middle or upper parts of the spinal cord, the pathways in the lower part of the spinal cord may still be intact. If this is the case, stimulating your penis directly, most helpfully with a vibrator, could result in an erection. You could also induce an erection by placing the (non-erect) penis in your partner’s well-lubricated vagina – with your partner sitting astride you. However, it is important that this is undertaken carefully, for if sensation levels are low, your penis might be damaged by being folded over, without this problem or any subsequent injury, being realized at the time. There are a range of devices used in treating men’s erectile problems, although many of them are now being replaced with Viagra or other related drugs, because they are less intrusive and more effective. Vacuum pumps The least intrusive of these options is the vacuum pump, which should be available to you on prescription. A tube is placed over the flaccid 64 MANAGING YOUR MULTIPLE SCLEROSIS penis, sealed at the bottom round the base of the penis, and air is pumped out either manually or by a battery-operated pump. A band is then slipped from the bottom of the pump around the bottom of the penis, the pump removed and the penis then stays erect with the blood trapped inside. It is important not to keep the band round the base of the penis for longer than 30 minutes, and the placing of the band round the bottom of the penis may require some dexterity. Injections,prostheses and aids Other more intrusive forms of erectile assistance include penile injections that relax the smooth muscle normally inhibiting blood flow into the penis, thus allowing an erection; or penile prostheses that can be inserted surgically that allow an erection to take place with various forms of mechanical assistance. There are a wide range of issues and concerns relating to the use of penile injections and prostheses, and both require an exceedingly well- organized and planned approach to sexual activity, and intercourse in particular, which some have found difficult to reconcile with anticipated emotions and feelings. If Viagra, Cialis or Levitra are not available, then you should seek a referral from your GP or neurologist to a physician specializing in these other techniques. There are also a number of artificial aids that do not require medical consultation or prescription, and these may include latex or similar penises, some of which are hollow and can incorporate a flaccid penis. Vibrators and other aids in the form of a penis are also available in sex shops or by mail order. Psychological problems and ‘libido’ Depression or fatigue, which are indirect (or secondary) symptoms of MS, may play as large a part in the way that you feel sexually as does primary neurological damage. If such symptoms are treated successfully, then your sexual drive (often called your libido) may increase. If the primary cause of your decreasing sexual drive lies in primary neurological damage, then this is harder to deal with directly. You and your partner could consider first sensual activity experiences, without you feeling the immediate pressure for sexual intercourse. Ensure that you make time to enjoy the experiences with each other without feeling hurried or under pressure. As in other relationships where circumstances SEXUAL RELATIONSHIPS 65 change, new, and possibly exciting and stimulating, patterns of mutual exploration may need to be learnt or re-learnt.

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The therapist can help the couple to understand the relational impact of their dual trauma status and ensure that the sexual abuse survivor is not perceived as the more dysfunctional spouse generic orlistat 60mg with visa. ASSESSMENT ISSUES How do you make the assessment with couples who present for couples therapy to rule out the possibility that one member was sexually abused? Treating Couples with Sexual Abuse Issues 279 Because many family dynamics and familial factors are related to a history of child sexual abuse (adverse family conditions: Fergusson order 60 mg orlistat amex, Lynskey buy 60 mg orlistat fast delivery, & Horwood buy 120mg orlistat free shipping, 1996; Fleming generic orlistat 60 mg on line, Mullen, & Bammer, 1997; poverty and parental maladjustment: Svedin, Back, & Söderback, 2002) a complete family-of-origin history must be obtained from each spouse upon the initiation of couples therapy. In the course of history taking, the therapist inquires of each part- ner whether he or she has a history of any type of abuse or trauma. Because a direct question may not yield useful information, especially if the partner is not aware of the abuse history, a good way to introduce the subject is to ask, "In what ways have you been hurt in your life? If, on the other hand, this question elicits information about sexual abuse that is new information to the partner, he may feel betrayed and angry that such an important part of his loved one’s history has been kept from him. The therapist must acknowledge his feelings and educate the couple about the secrecy and concealment that usually accompany sex- ual abuse, while simultaneously attending to the acute emotion likely to be experienced by the survivor at her acknowledgment. If this is the first time that the survivor has spoken about her abuse, there is likely to be a mael- strom of emotions and needs that must get high priority in treatment. The delicate nature of the issues that underlie this couple seeking therapy re- quires that individual therapy take precedence over the couples therapy. The competent therapist is likely to refer the survivor to a highly skilled cli- nician who specializes in working with this population and to defer cou- ples work until a later time (Oz, 2001). The therapist may also want to recommend a support group or individual therapy for the partner who is likely to develop many needs during the course of the survivor’s therapy. In some cases, her admission of abuse may stimulate a parallel admission on his part. In all cases, couples therapy can only proceed once the survivor has achieved a level of stability that will allow her to explore other issues in her relationship. CASE STUDY Recall Maria Elena and Jose whom we met at the beginning of the chapter. In our intake with the couple, we learn about Maria Elena’s sexual molesta- tion by her stepfather at age 9. Al- though Maria Elena has been in ongoing individual therapy to work on her incest issues, it will be important for her to continue to do so while the cou- ples therapy is undertaken. The couples therapy is important because, even though she has been working on her abuse issues in individual therapy, the couples issues have persisted. Nonetheless, while working in a couples modality, issues related to the sexual abuse must be seen as primary and other issues must often take a back seat. Models such as TRIAD provide a framework for understanding Maria Elena’s molestation. TRIAD is a trauma assessment tool developed by Ann Burgess (Burgess, Hartman, & Kelley, 1990), which allows identifica- tion of key aspects of Maria Elena’s molestation experience. The "T" in TRIAD refers to the type of abuse experienced, with sexual abuse having more serious emotional consequences than either physical or psychological abuse. Whether the molestation consisted of a single episode or multiple ones over time will inform us as to the amount of damage we can expect. The nature of the perpetration and whether vaginal penetration was involved is also re- lated to severity of symptoms. Sexual abuse survivors can look highly functional on the out- side—most are very competent but focused on controlling their environ- ment—and that makes it more difficult to identify it and to counter their denial. As with the intensity of the perpetration, the period of time over which molestation occurred will also relate to the severity of symptoms one can expect. In this case, the apparent sexual dysfunction that Maria Elena and Jose bring to couples therapy is symptomatic of the underlying sexual abuse is- sues. Maria Elena’s behavior in compensating for her abuse and Jose’s reac- tions to Maria Elena’s behavior are reflective of the circular interactions that become problematic in some couples and these become the focus of couples therapy. In the case of Maria Elena and Jose, both Latino, the therapist is wise to consider the traditional family structure of their culture. According to Sue and Sue (2003), "traditional Hispanic families are hierarchical in form with special authority given to the elderly, the parents, and males. Also, the therapist must consider the role of machismo, Jose’s reactions to Maria Elena’s lack of sexual interest and the importance of Jose’s sexual function- ing on the couple’s interaction. Other interactional issues that are common in couples where childhood sexual abuse is a factor include: difficulties with trust, emotional expres- siveness and intimacy, communication, substance abuse, eating disorders or other addictions, and issues related to household, money, time manage- ment, and parenting (Oz, 2001). Although these issues are common in many types of couples, when they occur in the context of sexual abuse, the etiology of these problematic relational patterns and their impact on the re- lationship can be decidedly different than in other couples. The assessment Treating Couples with Sexual Abuse Issues 281 includes identifying which of these relational issues are operating but look- ing at them through the context of sexual abuse.

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Contiguous infections can occur in trauma patients with open fractures buy 60 mg orlistat with visa, in bedridden patients with decubitus ulcers orlistat 120 mg without prescription, and in patients with a diabetic foot order orlistat 120mg free shipping. Localizing symptoms are more prevalent in the adult population as opposed to the pediatric population generic orlistat 60mg, allowing for more dedicated anatomic imaging with MRI cheap orlistat 120 mg without prescription, rather than a survey with radionuclide bone scanning. Epidemiology The annual incidence of osteomyelitis in children under 13 years of age is 1/5000 (13). With boys slightly more often affected than girls, fast-growing long bones such as the tibia and femur are the most affected regions. Although a single bone is usually affected, polyostotic involvement has been reported in up to 6. Clinical presentation can be confusing, and many laboratory findings such as elevated sedimentation rate may be sen- sitive but not specific. Infections in infants and neonates are usually clinically silent, and toddlers may present with limping, pseudoparalysis, or pain on passive movement (19). Half of the cases of septic arthritis occur in children less than 3 years of age (20). Approximately 53% are isolated cases of septic arthritis and 47% are cases of septic arthritis associated with osteomyelitis (21). Conversely, 30% of patients with osteomyelitis have adjacent septic arthritis (22). The most common symptoms are pain, fever, refusal to bear weight, and joint swelling. Most cases involve a single joint, although up to 15% of cases can affect multiple joints. Similar organisms to those in osteomyelitis are found in septic arthritis, including S. The most common sequelae of septic arthritis include joint instability, joint function limitation, and limb shortening (25). Overall Cost to Society No data were found in the medical literature on the overall cost to society from the diagnosis, treatment, and complications of acute hematogenous osteomyelitis or septic arthritis. Although there are several cost-effectiveness analyses evaluating the type, extent, and route of antibi- otic administration in the treatment of osteomyelitis and septic arthritis, no cost-effectiveness data were found in the literature specifically incorporat- ing imaging strategies in the management of acute hematogenous osteomyelitis or septic arthritis. Goals In acute hematogenous osteomyelitis and septic arthritis, the goal is early diagnosis and treatment to prevent the long-term sequelae of these diseases, which include growth disturbances, joint instability, chronic infection, malalignment, and limb deformity. The standard treatments include intravenous antibiotics and/or surgical debridement. Septic arthri- tis usually requires surgical therapy in order to decompress the intraartic- ular pressure. Surgical debridement may be necessary for osteomyelitis if frank pus can be aspirated from the bone, if there is necrotic bone present, or if there is failure to respond to antibiotic therapy (15,26). Methodology The authors performed a Medline search using PubMed (National Library of Medicine, Bethesda, Maryland) for data relevant to the diagnostic performance and accuracy of both clinical and radiographic examination Chapter 14 Imaging of Acute Hematogenous Osteomyelitis and Septic Arthritis 263 of patients with acute hematogenous osteomyelitis and septic arthritis. The diagnostic performance of the clinical examination (history and physical exam) and surgical outcome was based on a systematic litera- ture review performed for the years 1966 to 2004. The clinical examina- tion search strategy used the following terms: (1) acute hematogenous osteomyelitis, (2) septic arthritis, (3) pediatric, (4) children, (5) clinical examina- tion, (6) epidemiology or physical examination or surgery, and (7) treatment or surgery. The search strategy used the following key words: (1) acute hematogenous osteomyelitis, (2) septic arthritis, (3) magnetic resonance imaging or MRI, (4) bone scan, (5) ultrasound, and (6) imaging, as well as combina- tions of these search strings. What are the Clinical Findings that Raise the Suspicion for Acute Hematogenous Osteomyelitis and Septic Arthritis to Direct Further Imaging? Summary of Evidence: The clinical presentation of acute hematogenous osteomyelitis and septic arthritis can be confusing and nonspecific in the pediatric population. No single clinical finding in isolation leads to the diagnosis of osteomyelitis or septic arthritis. Repeat high-resolution imaging may be required to determine the need for surgical debridement, including extension into soft tissues or complications that are not amenable to systemic antibiotic therapy (limited evidence). Supporting Evidence: Standard laboratory tests such as elevated sedimen- tation rate can be nonspecific or even normal (19) (limited evidence). Serial blood cultures are reported to be positive in 32% to 60% of cases (1,17,18) (moderate and limited evidence). These aspirations can yield positive cultures in 87% of cases (27) (limited evidence). Toddlers can present with limping, pseudoparalysis, or pain on passive movement (4,28) (moderate to limited evidence).

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Department of managed care orlistat 120 mg without a prescription, such global changes are equally difficult to Health and Human Services; 1987:6(13) generic 120 mg orlistat with mastercard. A ran- ing that a chronic disease self-management program can domized trial of comprehensive geriatric assessment in improve health status while reducing hospitalization: a the care of hospitalized patients buy orlistat 120mg line. Silverman M buy discount orlistat 120mg online, Musa D 60 mg orlistat fast delivery, Martin DC, Rave JR,Adams J, Ricci ability and managing chronic illness in frail older adults: a EM. Evaluation of outpatient geriatric assessment: a randomized trial of a community-based partnership with randomized multi-site trial. A Controlled Chronic care clinics: a randomized controlled trial of a new trial of inpatient and outpatient generic evaluation and model of primary care for frail older adults. The effectiveness and efficiency of outpatient group outpatient visits for chronically ill older HMO geriatric evaluation and management. Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, continued geriatric outpatient management on health Kowal J. Physician imple- process of care in hospitalized older patients: a randomized mentation of and patient adherence to recommendations controlled trial of acute care for the elders (ACE) in a com- from comprehensive geriatric assessment. Outpatient geriatric evaluation and care to prevent cognitive and functional decline in hospi- management: results of a randomized trial. Boult C, Boult LB, Morishita L, Dowd B, Kane RL, patients with congestive heart failure. A randomized clinical trial of outpatient comprehen- of impact of model of integrated care and case management sive geriatric assessment coupled with a intervention to for older people living in the community. Keeler EB, Robalino DA, Frank JC, Hirsch SH, Maly RC, home care services on hospital use. Comprehensive Geriatric Assessment and Systems Approaches to Geriatric Care 203 33. In: Grosel C, Hamilton M, controlled trial of nurse case management of frail older Koyano J, Eastwood S, eds. Albert A variety of cognitive disorders occur with increasing is much that a geriatrician can do to identify the presence frequency as people age; these include progressive de- of cognitive dysfunction and see that it is properly menting disorders, acute confusional states, and cognitive assessed. Epidemi- ologic studies indicate that approximately 15% of the population over 65 years of age suffers from some form 1 Interview with Patient of dementia. However, the probability of having a dementing disorder increases dramatically with age. Data There are two sources of information concerning the concerning the prevalence of dementia in a community- cognitive status of patients: (1) patients themselves and dwelling population indicate that between the ages of 65 (2) patients’ families. Unless a family member has and 74 years the prevalence of dementia ranges from 2% approached the physician with concerns about the to 3%; this increases to 22% to 23% among those persons patient’s cognitive function, it is not likely a family 75 to 84 years and to 47% to 48% among those persons 2 member will be routinely involved in a geriatric assess- aged 85 years and older. Therefore, the physician is initially limited to to the incidence and prevalence of acute confusion in information that is obtainable from the patient. Several studies have information can be most easily gathered in two ways: (1) reported that 25% to 35% of hospitalized geriatric from an interview of the patient in the course of con- patients on a general medical service who are cognitively ducting a medical evaluation and (2) from brief mental intact at admission develop acute confusion. There are few systematic studies of the preva- lence of cognitive disorders secondary to psychiatric Medical Examination syndromes, but numerous clinical reports state that their prevalence is greater among elderly patients than young In the course of a routine medical examination, there is patients. Because the bidity and mortality, and although only some of them can most common causes of cognitive decline in elderly be completely reversed with treatment, appropriate man- patients produce a memory disorder (specifically a dif- agement can substantially improve the quality of life and ficulty with learning and retaining new information), reduce the development of secondary conditions. Thus, it greatest emphasis should be placed on ascertaining infor- is in the best interests of the patient if one can become mation about the memory function of the patient. This increasingly attuned to the possible presence of cognitive may be accomplished by a discussion of current events. For focuses on the role of neuropsychologic testing in the one patient; it may be politics, for another, sports, and assessment of cognitive dysfunction in elderly patients, for another, the stage of the planting season. If there is a particularly as it applies to the geriatrician, because there particularly dramatic event in the news that most people 205 206 M. There- plane crash), this may be useful for persons of diverse fore, it is ideal if this can be supplemented by a brief test backgrounds. Exam (MMSE),7 the Blessed Dementia Scale (BDS),8 Many patients in the early stages of dementing disorder and the Short Portable Mental Status Questionnaire can make general all-purpose remarks that appear to be (SPMSQ). Language prob- Of these, the MMSE has most commonly been used in lems are important to assess because they are common in clinical settings. The patient’s comprehension ability can be ability, set shifting) in a simple and straightforward evaluated during a medical examination with relative manner.

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